Take Two Apps and Call Me in the Morning

It may not be too long in our future when part of a prescription from our physicians may include and app (or two). This is the exciting idea of medically prescribed apps. Some futurists predict that doctors will prescribe FDA-approved apps to treat patients. So far, the FDA has maintained that it will only vet apps that perform device-like functions, such as making diagnostic determinations or treating ailments. The FDA has yet to release its full guidance on the regulation of mobile apps and will not go after the many available downloads that make untested medicinal claims until its rules are in place.

WellDoc is one of the pioneers in the prescription-app field. Its DiabetesManager system collects biometrics about a patient’s diet, blood sugar levels and medication regimen through manual input or from wireless devices. It then gives advice to a patient and sends clinical recommendations to the doctor. The Food and Drug Administration gave the system 510(k) clearance to operate as a medical device in 2010.

Happtique (health app boutique) is a company that operates a mobile app prescribing solution for healthcare called mRx. Happtique has recently launched a pilot that will test whether the company’s solution will encourage doctors to prescribe mobile software for patient use. mRx consists of Apple and Android smartphone and tablet compatible apps that focus on cardiology, rheumatology, endocrinology, orthopaedics, physical therapy and fitness training. The mRX system gives patients more structured guidance when it comes to selecting and using health apps and empowers them with tools to help them take a more active role in their care. And similar to traditional prescription, mRx will track how many times an app is prescribed as well as how many times patients click the “fill” button once the prescription is sent.

If the mRx trial is successful, it will help demonstrate that mHealth technology will be viewed as legitimate, powerful healthcare tools, not just fun programs to install on a phone or tablet.

From a behavioral point of view, the WellDoc and mRx systems can help encourage a dialogue between physicians and patients about available healthcare technology tools. These conversations will not only give patients additional resources, but will also encourage them to consider incorporating apps and other healthcare technology into their health management. In addition to increased health care provider connectedness, these systems also help achieve behavioral change and continued adherence through sustained influence over the patient’s multiple chronic states and enhanced patient self-determination.

When you think about it, these apps are no different from physicians prescribing a diet, a support group or any other resource. In fact, these apps will enable physicians to be more creative with the ways they engage their patients and provide the best care to them.

I am always pleased to hear that some industries are creating jobs. A recent report from Georgetown says: “Between 2010 and 2020, healthcare occupations will increase from 10.1 million to 13.1 million jobs. From 2010 to 2020, healthcare production will increase by over 70 percent, from $1.8 trillion to $3.1 trillion. In the same period, there will be an estimated 5.6 million healthcare job vacancies.” In essence, Georgetown researchers are forecasting that the number of jobs will grow nearly 30 percent (adding in “replacement jobs,” those left open by retirements, deaths and resignations).

However, the study also indicates that 82% of the expected influx of jobs will require post-secondary education and training. This statement tells me that figuring out the healthcare system is going to become even more complex. This makes sense when you consider that all the new health-related technologies that (among other things) are requiring the increase in education from our healthcare workers. This made me shudder at the thought of getting sick, because I am not sure I will be smart enough to navigate this brave new world.

But then I read a recent article about a specific healthcare position called a “navigator”. In general the role of a navigator is to be a liaison among patients, particularly cancer patients, and their many doctors and other medical and related professionals. In other words, navigators help people through chronic disease management.

There are two kinds of navigators: one is a patient navigator and the other a nurse navigator. They sound similar; however, they are distinct. Patient navigators can be lay people or social workers whereas nurse navigators are registered nurses, usually with a bachelor’s degree.

Navigators are particularly helpful during cancer treatment because patients don’t always know what they need as part of disease management and survivorship. The navigators constantly assess a patient’s needs, which can be medical, such as follow-up exams and diagnostic testing, or peripheral facets, such as overall health and wellness moving forward. That could include nutrition counseling or the seeing a mental health professional.

Navigators, whether patient, nurse or some other derivative role is likely to grow substantially because there’s a need to coordinate care across so many settings. That makes me feel a little better with all the changes in healthcare coming my way. This seems like a role that may expand into other (non-cancer) areas. If this is true, then getting sick will be a little less scary as there will be someone to guide me through it all.

The Beatles had the right idea when they wrote the song “Come Together” (never mind that the song was actually a play on a political ad campaign from the 1960s).

If you’re like me, you’ve heard the song hundreds or even thousands of times and never thought too deeply about the lyrics. Let’s face it; they don’t make a lot of sense on their own. Some have speculated that the song references the personalities of different members of the band (i.e. “one holy roller” for George Harrison, the “spiritual” Beatle). Or possibly, it’s just the result of some other illegal, “creative influences.”

As I’ve been researching journal articles and reading blogs and editorials on healthcare reform, I’ve been struck by the fact that so many of the proposed changes to the system are about making healthcare more collaborative. It’s about providers, patients, and other stakeholders coming together. Just take a look at three of the proposed changes—Accountable Care Organizations (ACOs), Insurance Exchanges, and Patient-Centered Medical Homes (PCMHs).

Accountable Care Organizations

ACOs are one of the most anticipated aspects outlined in healthcare reform. The idea is that all sorts of providers, including physicians, specialists, and hospitals will come together to provide care that focuses on quality rather than volume of services. Kind of sounds like an HMO, right? Well, not exactly. One of the major differences between ACOs and HMOs is that ACOs give their patients the option of going to providers outside the ACO network. ACOs would cover a minimum of 5,000 Medicare patients for at least 3 years. The goal of an ACO is for providers to work together to cut unnecessary healthcare costs while still providing quality services. If they are able to meet certain cost and performance measures, they’ll be reimbursed by Medicare according to their cost savings. To keep ACOs from dominating the marketplace, they’ll be subject to anti-trust and anti-fraud review processes. The moral of the story is that it’s advantageous to work as a team to save money and be reimbursed a chunk of the savings.

Insurance Exchanges

What happens to all the people who aren’t insured through their employer or are purchasing their own insurance? Prior to healthcare reform, those individuals would either end up paying higher premiums or choosing to forego insurance entirely. If the individual mandate stands, anywhere from 30-35 million people who were previously uninsured will be required to purchase insurance. With so many people buying insurance on their own, why not bring them together to leverage more affordable premiums? That’s exactly what insurance exchanges are designed to do. Exchanges will prohibit insurance discrimination against individuals with pre-existing conditions and bring together individuals and small businesses (with fewer than 100 employees) to purchase insurance. All exchanges will be required to have four different benefit categories of plans as well as a catastrophic plan. These exchanges will be run by states and are effective starting January 1, 2014. For more information on exchanges, see the Kaiser summary of healthcare reform.

Patient-Centered Medical Homes

In a similar vein to ACOs, PCMHs will bring together providers to enhance patient primary care. The difference between an ACO and a medical home is that ACOs are networks of providers, while a medical home is a team of primary care providers, usually made up of physicians, nurses, and physician assistants, who are assigned to a particular patient. The PCMH team is led by the patient’s personal clinician who works together with their team to coordinate care and promote overall patient health. This approach has been shown to be especially beneficial for patients with chronic conditions, but is also an effective approach for other groups of patients, as well. The Affordable Care Act provides an incentive for PCMHs—they can receive reimbursement for caring for patients with chronic conditions who are covered by Medicaid.

Even though the lyrics of “Come Together” may not make all that much sense, the message certainly applies to the changes we’re seeing in healthcare today. Healthcare is moving in the direction of collaboration and it’s moving quickly. Most of the changes mentioned above are already being implemented or in the final stages of planning. Only time will tell how these changes actually stand up to all the hype, but for now, it looks like the one thing is for sure–patients, providers, and others are coming together, right now, over the health concerns of you and me.

The tablets I am talking about are not the drug kind but iPads and other mobile devices. It is clear that physicians are adopting the use of tablet devices in their practice, and they seem to be using them more and more every day. This Technology Review video helps explain why physicians gravitate to these small, mobile devices. In essence, tablets allow physicians to bring real-time, accurate data right to the patient’s bedside – fast, easy and convenient.

However…my real story is how the medical schools are adopting tablet technology to change educational and training methods and ultimately practice methods.

Recently, each member of the incoming class of 2015 of Irvine’s School of Medicine received an iPad as part of its initiative to provide students with a digital medical education. And this was the second year Irvine has done this. The iPad is a core component of the school’s innovative iMedEd Initiative, which officials say has grown into one of the most comprehensive, fully digital medical education programs in the country.

Include Yale’s School of Medicine with the growing list of medical schools that are embracing the iPad as a primary source of medical teaching. This upcoming year, Yale will be giving an iPad 2 to all 520 of their medical students. iPad 2s will provide professors with new classroom tools, including clearer graphics and the ability to change course materials as often as necessary.

According to mobihealthnews.com, the following nine schools have embraced tablet-based teaching: Brown Alpert Medical School, Georgetown University School of Medicine, Ohio State College of Medicine, Stanford School of Medicine, UCLA School of Nursing, University of California Irvine School of Medicine, University of Central Florida College of Medicine, and University of Minnesota Medical School.

What this all means is that while the iPad, specifically the iPad 2, is not quite a game-changer in and of itself (at least anymore), it certainly has accelerated trends in healthcare education and training that were developing – or should I say were inevitable.

You’ve heard us say this before: adherence to medication is a problem. You’ve heard us say this before too: improving adherence is not as simple as reminding people to take their medicines and giving them co-pay assistance.

Those who undertake the development of adherence programs should be prepared to invest considerable effort and resources. In the face of expiring patents and new drugs entering the market, it’s no surprise that companies focus on acquisition and conversion rather than on keeping patients on existing drugs… until you get the numbers.

“A new report conducted by the New England Healthcare Institute (NEHI) found that not taking medications as prescribed leads to poorer health, more frequent hospitalization, a higher risk of death and as much as $290 billion annually in increased medical costs. Anywhere from one-third to one-half of patients in the U.S. do not take their medications as instructed.”

Bottom line, we all need to do better when it comes to adherence: Patients need to do better,  doctors need to do better, pharmacists need to do better, and pharma companies need to do better. A co-worker and I recently discussed his issues with adherence over a company lunch. A lunch at MicroMass, a company that develops adherence programs! Adherence is hard for all of us.

Or at least that’s how we feel now. Here at MicroMass, we are beginning a systematic analysis of branded adherence programs for the management of chronic conditions. We anticipate seeing a lot of the reminder+savings card packages we’ve criticized, maybe a few partially behaviorally-based programs, and a sprinkle of the customized, comprehensive, easy-to-use gold-standard programs we strive for. Stay tuned for a white paper detailing the best practices for patient adherence and the nitty-gritty on what’s out there.

Technology advancement surrounds us. GPS, iPhones, you name it – it’s so expected that it’s become a part of our everyday lives. Science and medical advancements are no different. There are new devices, procedures and therapies surfacing every day.

I, for one, appreciate and take advantage of these technology advancements on a daily basis and I also take comfort knowing that should my health decline, there is hope, given the wealth of expertise within driving distance from my home.

But as I was reading a few recent articles related to patient-physician communication, I have to wonder – have we lost touch with the fundamentals of human touch and care? I am not trying to point fingers at physicians and their poor communication skills anymore than I am pointing fingers at patients who often don’t take the initiative to ask the right questions or try to act as partners in their care. Yes, I do believe that there is a lack of decent communication skills, but what I really question is that fact that as a society we don’t seem to value in-person communication skills, at least they way that maybe we once did.

Communication can be powerful. I don’t think anyone would argue that point. But did you know that communication can be healing?

A recent patient-physician communication study by Robins, et al. demonstrated the benefits of transparency.  When physicians were more transparent and took the time to explain their actions during physical exams as well as their reasoning behind clinical decisions – this promoted greater patient understanding and collaboration.  Other studies examining physician transparency in communicating have illustrated outcomes such as greater patient adherence, reduced uncertainty and symptom relief. If improved health outcomes are not enough, some research has also demonstrated that patients were less likely to sue their physicians if they felt that they had received adequate information and advice.

The art of listening is just not an abundant trait anymore, especially in medical encounters. A recent commentary in JAMA by Dr. Wendy Levinson and Dr. Philip Pizzo (both affiliated with the University of Toronto) states that “excellent medical care combines sophistication in scientific knowledge with equally sophisticated communication skills to understand the needs of the individual patient.”  The authors go on to cite the many barriers to effective physician communication skills such as reduced time and increased volume of patients, handoffs between physicians, and lack of communication training in residency programs.  No different than many of us, physicians are under intense pressure to be productive and that productivity is most often associated with number of patients seen.

In the US, an estimated 30-40% of physicians are experiencing burnout. And burnout leads to reduced empathy, greater dissatisfaction, and reduced patient adherence.

A major shift needs to occur. I think as patients and consumers, we need to expect and demand that physicians communicate with us in a way that is respectful and that allows us to be as collaborative as possible. But a major shift at a higher level will also be required – laws, processes and infrastructures that assign value to communication – that financially reward physicians who incorporate positive communication skills – and greater emphasis at the research and medical school faculty level. I hope that I witness this advancement during my lifetime.

Wireless technology used to track packaged items has made a big turn towards healthcare monitoring. New technologies that you wear will help doctor monitor your vital signs and your compliance to prescription medications.

One such device consists of a Band-Aid looking patch and microchips attached to your pills. When the microchips are activated by your stomach fluids, they will send a signal to the patch. When you get near your smart phone, the data collected by the patch will be uploaded over the Internet. If you give permission, this data can be shared with your doctor. The device is being pioneered by Proteus Biomedical, a company that started with their smart-pill system.

These kinds of devices will have a profound effect on health care. The near real-time data can help your doctor help you almost immediately if events in your life keep you from taking your medication as prescribed.  This should benefit you in a couple of ways. First, if you have a chronic disease, like hypertension, it will enable you to take greater control of your condition and your health. Second, it will provide your doctor with more accurate information. All of this should help you avoid costly hospital stays – and that is money saved.

Many believe these kinds of extensions to current health care practices is the key to cutting costs. This is just the beginning of remote monitoring, especially for the most acute cases. If these devices can keep enough people from going to the hospital unnecessarily, hospitals can utilize their limited resources more effectively.

Proteus is one of many companies with wireless monitoring technologies. Coventis is developing CardioMems to address congestive heart failure conditions (watch the video below); Cambridge Consultants is developing PHT to tackle asthma; DexCom is developing SEVEN PLUS for diabetes; and Airstrips Technologies is developing Airstrip for obstetricians (watch the video below).

These medical devices are putting a whole new twist on wearable, wireless technology.

We lift weights to improve strength, run laps to maximize conditioning and tailor our diets to ensure our bodies of nutrients needed to perform. All are areas worthy of attention not only for our overall health, but for both our internal mindset and external appearance. The fact that these elements are regular fixtures of our day-to-day routine is of little surprise (it’s more surprising if they’re not part of our complete breakfast). What is a bit awe-inspiring, however, is how frequent our brain is passed over as a body part that stands to benefit from a little exercise.

Our brains are complex; easily the most complicated and mysterious feature of our bodies. It’s also easy to overlook the brain since it’s a part we (and others, hopefully) can’t see and have no way of truly tangibly attributing the impact we can make regarding its performance. To state the obvious, without proper communication from the center of our nervous system, arms won’t lift, feet won’t push and mouths won’t open. Then shouldn’t it seem like the obvious thing to do to have a plan we can follow geared toward optimizing the performance of our single feature that’s at the controls of everything we do?

Outside of the routine digestion of words, thoughts and visuals, most of us exhibit little conscious effort toward injecting the brain with some extra muscle (have we ever really thought of reading a comic book or speaking with Aunt Edna as brain fuel, anyway?). Yes, the statement about us using only 10% of our brain is false; we use all of our brain, some just use it better than others. Or do they? Could it be that some just settle for the brain capacity their given, which is the equivalent of eating a bag of popcorn before it’s popped? Sure, it still has some of the taste and will fill your belly, but it lacks all of the buttery goodness and flavor if we actually put it in the microwave for a minute (sorry, bad example for a ‘health’-related topic).

A recent article in Smart Money examined a growing trend of flexing our mental muscles  – known as brain plasticity – in places like brain gyms and through activities typically associated with the, shall we say, less chiseled. From phone applications to video games to whatever else fills the $265 million mental-fitness-product market, more and more are setting out to improve their health and strength through brain training that works just like weightlifting: undertake difficult and unfamiliar activities that force new connections to be formed. Memory, attention span, stress and aura are just some of the attributes that stand to be affected by a mental fitness program, not to mention more obvious benefits like sharpened response times, better problem solving ability and heightened awareness.

Academics warn not to expect too much too soon from these products, but brain stretching brings to the surface some underutilized points of potential for pharma marketers. From metabolic management research, we already know behavior can be changed by better understanding a patient’s mindset, improving the odds of adherence to a prescription or helping curtail unhealthy behavior, such as smoking. Providing doctors with the tools to more easily identify those mindsets, however, is an area where the concepts of gaming, interactive exercises and smartphone applications might provide doctors with the behavioral insight needed to improve their patient’s lives. Even without a doctor’s presence, custom-built programs and challenges specifically for helping guide a patient’s thought process regarding a condition or treatment can be effective in driving motivation and communicating in ways physicians can’t.

We all know reshaping human behavior is no easy feat, but it’s virtually impossible without a greater understanding of what’s going on in someone’s mind. Whatever windows into that world are available must be considered, especially if science is on its side. Although creating effective training programs will likely be expensive and difficult to personalize, it’s a step in the right direction and one of the few solutions that might help both patient engagement and patient-physician communication. That’s truly some heavy lifting.

Quick quiz for you: How many of you know what your VO2 max is? Your lactate threshold? How about recovery heart rate? Or resting heart rate?

Maybe those are too tough. Let’s try a few more…What’s your blood pressure? How about total cholesterol? HbA1c level?

I imagine many more of you were able to answer questions from the second group than the first. If so, then that’s great – you’re more aware than many people about potential risk factors for disease.

But let’s look at that first group a little more closely. These are all measures of physical fitness. They don’t get much attention because they’ve traditionally been associated with elite athletes in competitive sports rather than your average John or Jane Doe, though all of them can be measured or generally estimated without expensive equipment or laboratory blood work.

It’s a shame, because it would be nice to see people taking such proactive control of their health to the point that they are measuring how much more fit they are becoming, rather than how well they are avoiding illness.

The other reason these are less known is that there isn’t a pill you can take to improve them (though some do try). In many ways we can thank pharma manufacturers for helping us (and our physicians) to become more educated about biomarkers for disease. But their commercial goals don’t usually include improving patients’ physical fitness.

So how do we improve our healthcare providers’ knowledge level and ability to counsel patients on improving their physical fitness? One way might be to make them role models for their patients – one study has shown that physically active physicians are more likely to counsel their patients about exercise.

That’s a good start, but it still leaves room for improvement. Research out of Canada has shown that a majority of physicians recognize the need for counseling their patients about exercise, but relatively few actually test their patients’ fitness or provide specific instructions on what to do.

Giving patients information on how to become more fit takes care of another piece of the puzzle, but if you want to increase the likelihood they will change their behavior, you have to understand their motivation and deliver that information in a way that they will respond to.

It’s a lot to consider, but exorbitant healthcare costs and healthcare reform are going to put preventive medicine much more in the spotlight, so we may as well start now.

Which would you respond to?

“Your lab results indicate you are likely to develop type 2 diabetes.”

or

“Your lab results indicate you have an 80% likelihood of developing type2 diabetes in 5 years.”

I know I would react more strongly to the second message. The authority that the absoluteness of the percentage demonstrates coupled with the sense of urgency of the time frame would make me take notice – actually, it would put me on notice.

 That is exactly what may come about with Tethys Bioscience, Inc.’s new diabetes risk score (DRS) test called PreDx®. According to Tethys, PreDx DRS reclassifies a vast “at-risk” diabetes population (currently 57 million) into more clearly differentiated risk categories, and identifies those individuals at highest risk of developing diabetes within the next 5 years. PreDex DRS uses quantifying biomarkers suspected of playing roles in diabetes development. In other words, this is personalized medicine in practice. It is taking you personally (literally) by directly measuring your body to generate your diagnosis. You can read more about PreDex DRS in this Technology Review article.

Armed with this more direct measure and more quantified risk assessment, doctors can now deliver the diagnosis in a new and more compelling way. Not only can the diagnostic test be more personal, but the delivery of the diagnosis can as well. Behavioral science tells us that because of our various behavioral biases, how a diagnosis is delivered can impact how we receive and act on it. You can watch a CBS Interactive SmartPlanet video segment that focuses on the impact of the PreDx® DRS on the physician and patient.

…which brings me full circle to ask, “Which would you respond to?”…